6. Exposición 46
6.3. Simulación del control
6.3.3. Interfaz
It is estimated that the percentage of the population aged 50 years and older requiring substance use treatment will increase from 4% in 1995 to as high as 34% by 2020 (Wu &
Blazer, 2011). In addition to the common underdiagnosis of SUD comorbidities in older populations, adults over the age of 60 are often excluded from clinical trials examining the safety and efficacy of existing or new treatments for SUDs.
That said, the existing models of SUD treatment — including direct observation and methadone maintenance (in specific subgroups of individuals who use substances), motivational interviewing and cognitive behavioural therapy — have been shown to enhance adherence and reduce substance use in older outpatients (Durvasula & Miller, 2014).
The effects of aging on the reward system and the psychological changes that occur with advancing age (e.g., greater wisdom, less risk taking) might have an influence on the types and patterns of SUDs experienced by older adults, as well as the effectiveness of behaviour change (Lim & Yu, 2015). Existing comorbid medical and psychiatric disorders could also influence treatment choices and options. The distinctive biological and psychosocial characteristics of older adults that predispose them to addiction, along with other risk factors such as polypharmacy, must therefore be considered when using various treatment options.
Treatment programs specific to older adults have been shown to have better retention rates in experimental groups compared to control groups (Kofoed, Tolson, Atkinson, Toth, & Turner, 1987). These programs include pharmacological options, psychosocial interventions and integrated approaches.
5.4.1 Pharmacological Options
Depending on the SUD, there are several pharmacological treatments available for older adults. Given the age-related pharmacokinetic and pharmacodynamic changes, the level of dosing required for older populations is generally lower than that of younger age groups. To date, most of the research in this area has focused on medications for treating tobacco smoking and alcohol use in older adults.
Pharmacological treatments for tobacco use include 5.3.6 Chronic Pain
Over the past decade, many older adults have reported the non-medical use of prescription drugs for chronic pain.
The non-medical use of prescription drugs has become part of an invisible epidemic of polypharmacy in older adults (Kalapatapu & Sullivan, 2010). The drug used most often by baby boomers to relieve the symptoms of chronic pain and physical health conditions is cannabis (Lau et al., 2015a). It is a common misperception that there is minimal risk in using cannabis, especially when compared to other illicit drugs or alcohol. Many older adults view cannabis as a safer alternative, with a low risk of addiction and less-adverse side effects (Lau et al., 2015b). Yet trauma patients aged 50 years and older who test positive for cannabis have higher odds of hospital admissions, operations and stays than those who test negative.
Most adults who smoke cannabis in later life have been doing so since their teens; this long-term use could be associated with the exacerbation of existing physical and mental health problems (Choi et al., 2016). A higher prevalence of older adults using cannabis today compared to previous generations could have implications for the healthcare system, such as increased healthcare costs resulting from longer hospital stays caused by cannabis-related adverse events (Pacula, Ringel, Dobkin, & Truong, 2008).
5.3.7 Conclusions
Medical conditions co-occurring with SUDs in older adults are highly prevalent. While healthcare providers can easily rule out serious physical problems such as heart conditions, diabetes, HIV/AIDS or chronic pain in younger patients, it is not as clear and straightforward in older patients. Given that common medical disorders can influence SUDs in the older adult population, better diagnostic and treatment options are needed.
In individuals with SUDs and HIV/AIDS, gay-specific CBT and social support therapy (which contextualize treatment to the societal and interpersonal experiences of gay men) have resulted in two-fold decreases in substance use (Durvasula & Miller, 2014). Educational groups, which use similar concepts and processes as those found in CBT, have also been found effective in older adults with SUDs (Kuerbis et al., 2014).
5.4.3 Integrated Care Approaches
In general, compared to younger adults, older patients have been found to engage well and over a longer duration of time in integrated treatment programs that include combinations of psychosocial and pharmacotherapy (Lemke & Moos, 2003). For example, motivational interviewing has often been integrated into methadone maintenance programs, resulting in less risky sexual activity among individuals with HIV/AIDS and co-occurring SUDs (Durvasula & Miller, 2014). However, the specific study demonstrating this result involved middle-aged individuals, signalling the need for additional research among older adults.
Integrating screening and brief interventions for comorbid SUDs and physical or mental health disorders into mainstream primary care could result in decreases in healthcare costs in older populations. Currently, the availability of such approaches is limited in the older adult population, which highlights the importance of appropriately involving older adults in existing integrated approaches.
In addition, given the age-related pharmacokinetic and pharmacodynamic changes, older adults might require lower drug doses compared to the general population.
Future studies should therefore seek to include older adults for treatment trials.
smoking cessation aids such as varenicline, bupropion and nicotine replacement therapies, such as nicotine patches (Tait et al., 2007). For alcohol use disorder, naltrexone and disulfiram have commonly been used and are effective at both reducing drinking and preventing relapse (Oslin, Liberto, O’Brien, Krois, & Norbeck, 1997). Treatment of opioid use disorder has commonly included methadone and buprenorphine/naloxone (Gossop & Moos, 2008).
Pharmacotherapies are less commonly used for SUDs co-occurring with physical and psychiatric conditions in older adults due to the numerous potential interactions of these medications with the drugs already being taken to treat the comorbid conditions. Nonetheless, some studies have been conducted in comorbid populations, such as one looking at the use of lamotrigine in adults with HIV using crack cocaine (Margolin, Avants, DePhilippis, & Kosten, 1998). Varenicline has also been shown to be effective in smoking cessation outcomes among patients with schizophrenia (Pachas et al., 2012; Williams et al., 2012) and bipolar disorder (Chengappa et al., 2014). However, these studies were completed in populations with mean ages of approximately 46 years.
5.4.2 Psychosocial Interventions
Several psychosocial interventions have been proven to be effective in older adults with SUDs, with some of the less-intensive options including brief interventions (such as relatively unstructured counselling) aimed at reducing substance use (Fleming, Barry, Manwell, Johnson, &
London, 1997). For instance, 10 to 30% of individuals who engage in problematic drinking have been found to reduce their drinking after just one to three brief intervention sessions (Fleming, Manwell, Barry, Adams, & Stauffacher, 1999).
If brief interventions are not effective in older adults, motivational interventions should be considered. Such techniques evaluate an individual’s willingness to change their substance use (Purath, Keck, & Fitzgerald, 2014).
Cognitive behavioural therapy (CBT) has also led to reductions in alcohol use in older adults with SUDs by helping them set goals and identify strategies for change (Morin et al., 2004). CBT has shown promise among older adults with co-occurring physical and psychiatric disorders (Edinger, Wohlgemuth, Radtke, Marsh, & Quillian, 2001).
Substance Use In Canada—Improving Quality of Life: Substance Use and Aging Substance Use In Canada—Improving Quality of Life: Substance Use and Aging
88 Canadian Centre on Substance Use and Addiction Canadian Centre on Substance Use and Addiction 89
and suicide. Also concerning is the prevalence of SUDs being under-reported due to stigma or underdiagnosis by healthcare professionals (DeMers, Dinsio, & Carlson, 2014;
McGinty, Goldman, Pescosolido, & Barry, 2015). Clinicians treating older adults often overlook SUD diagnoses, resulting in a lower index of suspicion for comorbidities that might otherwise present covertly as falls or cognitive impairment. However, surveillance data indicate that one in 10 admissions among the older adult psychiatric population are associated with an SUD, underscoring the importance of better treatment programs and recognition of co-occurring diagnoses.
Raising awareness of SUDs among older adults and their healthcare providers could help clinicians’ efforts to identify and treat these conditions. Knowing which mental health diagnoses are co-occurring with SUDs among older adults might also provide better risk prediction and decreased healthcare costs. The following chapter provides an in-depth examination into the screening and assessment of problematic substance use among older adults.
5.5 Conclusion
There is a clear need for specific programs that support older adults with SUDs. While alcohol is the primary problematic substance later in life, the increasing non-medical use of prescription drugs (such as opioids and benzodiazepines) and the increasing use of illicit drugs are emerging issues that need to be addressed.
By 2020, an estimated 56% of adults aged 50 years and older will have used drugs at some point during their lifetime — nearly double the rate (26%) reported in 2001 (Gfroerer et al., 2003). Even more alarming, the number of older adults who will require treatment for illicit drug use is projected to increase by 500% between 1995 and 2020 (Gfroerer & Epstein, 1999). With the world’s population of older adults expected to grow dramatically in the decades to come, the need for effective treatments and healthcare services targeting older adults with SUDs will likewise continue to grow. Furthermore, these numbers highlight the need to continue targeting younger populations, as doing so could help reduce the number of older adults with SUDs in the future.
The high prevalence of SUDs in older populations raises concerns, especially considering the potential impact of comorbid diagnoses such as psychiatric illnesses, hypertension, anemia, dementia, diabetes, delirium
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